Provider Demographics
NPI:1225263155
Name:31 MEDICAL GROUP
Entity Type:Organization
Organization Name:31 MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IDMT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:333-381-0501
Mailing Address - Street 1:PSC 103 BOX 3223
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09603-0033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 AMDS/SGPF
Practice Address - Street 2:UNIT 6180 BOX 245
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09601-0245
Practice Address - Country:US
Practice Address - Phone:001-632-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital